Limb WeaknessSTROKE: APROACH AND MANAGEMENT

BY DR. MUSTAFA F. AL BAGHDADI

Approach

Approach

Assess power, ask about pre-existing weakness & measure glucose.

Immobilize the cervical spine

Disk prolapse, pathological fracture & Spinal stroke

(severe back pain)Increase tone, Brisk reflexes, extensor planter responseSuggest

myelopathy Do MRI

syringomyelia,glioma, abscess

post-radiation myelopathy, sub-acute combineddegeneration of the cord, transverse myelitis, & ALS.

Signs of raised ICP, LP for CSF, brain MRI,

serum B12, autoimmune & infective screen

Guillain–Barré, diabetic neuropathy, acute intermittent porphyria, chronic inflammatory demyelinating polyneuropathy, & hereditary sensorimotor neuropathy.

Sensory loss pattern, Nerve conduction studies, LP, vital capacity,

Suggest myelopathy Do

MRI

Ocular and bulbar involvement (ptosis, diplopia, voice weakening), +ve tendon reflex, AChRAb,& chest CT.

myopathies

Stop statins, exclude other drugs,& antibody screen(anti-jo1).UMN or LMN ‘patchy’ pattern of

weaknessa

lumbosacral plexopathy, malignant, vasculitic or infiltrative disorder

Compare pulses, color, temperature,& capillary refill. Limb x-ray, CK, ask about seizure,& previous stroke.

Assess the risk of

impending stroke

Assessing the risk of impending stroke

Admit if ABCDD score ≥4 Or >1 TIA

Otherwise consider discharge with

appropriate secondary prevention and specialist follow-up within a week.

Arrange neuroimaging prior to discharge in any patient taking warfarin.

carotid Doppler USS

Compare pulses, color, temperature,& capillary refill. Limb x-ray, CK, ask about seizure,& previous stroke.

Assess the risk of

impending stroke

Further assessment of

strokeStep 1 Assess eligibility for thrombolysis Potentially disabling

stroke.

Less than 3 hours

immediate CT brain to exclude hemorrhagic stroke.

Step 2 Classify stroke according to clinicaland radiological findings

Perform a CT brain urgently if:

• the patient is eligible for thrombolysis

• coagulation is impaired

• ↓GCS

• symptoms include a severe headache

• there is a rapidly progressive neurological deficit

• cerebellar hemorrhage is suspected (to

exclude obstructive hydrocephalus).

Otherwise, perform CT within 24 hours

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Acute treatment & Prevention Acute Supportive treatment (airway protection,

oxygen, IV fluids) is initiated.

Aspirin is best if given within 24 hours of symptom onset.

Assess the patient’s ability to protect his or her airway, keep NPO, and elevate the head of the bed 30°.

Do not give antihypertensive agents unless one of the following three:

Prevention according to the cause:• atherosclerosis of the carotid arteries (Aspirin, Control HTN, DM, smoking, hypercholesterolemia, obesity, Surgery carotid endarterectomy in Symptomatic patients)• embolic disease anticoagulation (aspirin), reduction of atherosclerotic risk factors • lacunar strokes—control of hypertension

So if patient presents within 3 hours of stroke onset, thrombolytics areindicated. If after 3 hours, give aspirin. If patient cannot take aspirin, giveclopidogrel.

1- BP is very high >220/>120.2- medical indication for antihypertensive(MI, HF)3- receiving thrombolytic therapy

Step 3 Evaluate for risk factors/underlying cause

Suspect a cardiac source if :

• evidence of AF or MI• features suggesting endocarditis ,e.g. fever & new murmur• ≥2 cerebral infarcts• systemic emboli e.g. lower limb

Investigate for an unusual cause of stroke in younger patients without vascular risk factors:

• thrombophilia screen.

• echocardiography

• Consider MRA

Complications of Stroke

1. Progression of neurologic insult 2. Cerebral edema occurs within 1 to 2 days and

can cause mass effects for up to10 days. Hyperventilation and mannitol may be needed to lower intracranial pressure.

3. Hemorrhage into the infarction—rare 4. Seizures—fewer than 5% of patients

Compare pulses, color, temperature,& capillary refill. Limb x-ray, CK, ask about seizure,& previous stroke.

Assess the risk of

impending stroke

If no result do LP ± MRI

fever, meningism, purpuric rash, or features of shock blood cultures, give empirical IV treatment

Slowly progressive

suddenExclude

spinal cord

Or sensory level

If you can’t do brain CT or MRI if cranial nerve or cerebellar

signs +ve

Single peripheral n.

MRI spine

Still possible so we should do CT

ReferencesDAVISON’S PRINCIPLES

MACLEOD’S CLINICAL DIAGNOSIS

STEP UP TO MEDICINE

Thank youFOR YOUR ATTENTION